Sub-Saharan Africa has the highest HIV burden in the world, with 67 percent of the estimated 34 million people living with HIV. Globally, children under 15 years are particularly hard hit: 3.4 million are living with HIV, 90 percent of whom live in sub-Saharan Africa (WHO 2011a).
Approximately one-third of infants born to mothers living with HIV are not on antiretroviral therapy (ART), either for their own clinical care or for the prevention of mother-to-child transmission, and will be infected during pregnancy, birth, or breastfeeding. Until recently, it was assumed few children infected during this period would live beyond their fifth birthday. Recent data has emerged to challenge this assumption because children infected via vertical routes are now entering adolescence in sub-Saharan Africa. Recent projections suggest that 36 percent are slow progressors and have a median survival age of 16 even without access to treatment (Ferrand et al. 2009a). Moreover, many children who acquire HIV during the perinatal period and are subsequently on ART are now expected to live a long healthy life. However, they live with a host of clinical and psychosocial care needs that most community support and health systems in sub-Saharan Africa are not equipped to address (Ferrand et al. 2010; Li et al. 2010; Petersen et al. 2010; Valenzuela et al. 2009). With recent evidence showing that ART can prevent sexual HIV transmission among serodiscordant couples (Cohen et al. 2011), decisions about when to start treatment, adherence, and retention become even more critical to address among adolescents living with HIV. Transition can be both a mental and physical reality for all adolescents living with HIV, and services should promote self-care that includes adherence to ART and the adoption of appropriate individualized prevention strategies to help reduce further HIV transmission (The Lancet 2011a).